SHORTNESS OF BREATH - 65 Years old male patient came to the clinic wi...

JOSEPH CAMELLA

"SHORTNESS OF BREATH"

65 Years old male patient came to the clinic with the complaint of: • Chief

complaints: Shortness of breath, • HPI: 65 years old male presents with acute on chronic shortness of breath. Patient endorses 1.5 weeks of shortness of breath.Other associated symptoms include chronic productive sputum (yellow), chills, nausea, upper abdominal pain related to coughing, chest pain with coughing.Denies emesis, diarrhea, headache, dysphagia, myalgia

65 Years old male patient came to the clinic with the complaint of:

• Chief complaints: Shortness of breath,

• HPI: 65 years old male presents with acute on chronic shortness of breath. Patient endorses 1.5 weeks of shortness of breath. Other associated symptoms include chronic productive sputum (yellow), chills, nausea, upper abdominal pain related to coughing, , chest pain with coughing. Denies emesis, diarrhea, headache, dysphagia, myalgia • Past Medical History: Patient have the history of COPD on O2 at 2 LPM, Hypertension, Hyperlipidemia. No history of surgeries in the past.• Allergy Identification: Patient denies any food, drug, seasonal or latex allergies.• Medication Reconciliation: Patient Takes Albuterol 90MCG oral inhale 2 puffs every four hours as needed for SOB, Olodaterol/Tiotropium 2.5mcg/actuat 60 D 2 puffs daily for COPD. Guaifenesin 100mg/5ml takes 10 ml Q 6 hours as needed for cough.Atorvastatin Calcium 40 mg tab once a day in the evening for hyperlipidemia, Losartan 50 mg one tab once a day for hypertension.• Social History: Patient denies use of smoke, or any illicit drugs. Used to drink alcohol but quit drinking two years ago. Lives with daughter and grandson. Enjoy reading books and watching TV in his free time.• Family History: Father died at the age of 85, had the history of prostate cancer and hypertension, Mother died at the age of 74, had the history of arthritis and hypertension.Younger sister is alive and have asthma.• Heath promotion: Patient’s last follow up with his PCP was six months ago. Last eye and dental exam were lats year in December. Eats healthy heart diet. Goes for walk about once a week for 40 minutes, otherwise does not do any exercises. Retired Navy officer.Checks his Blood pressure once a week and keep log of the numbers. Patient uses rolling walker for long distance walking and cane for around the house. he reports being up to date on vaccines including flu and pneumonia vaccine and received both shots for COVID 19. He wears his mask when he goes out in public and maintains a physical distance of six feet while practicing good hand hygiene

ROS:

• General: The patient denies fever, fatigue, weakness, weight gain or weight loss.• Head, Eyes, Ears and Throat: Eyes – The patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and denies wearing glasses. The patient denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing.• Cardiovascular: The patient denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or

feet, heart murmurs, cramps in his legs with walking, pain in his feet or toes at night or varicose veins.• Respiratory: Patient complaint of acute on chronic shortness of breath. Patient endorses 1.5 weeks of shortness of breath. Other associated symptoms include chronic productive sputum (yellow), chills, nausea, upper abdominal pain related to coughing, chest pain with coughing. The patient denies coughing up blood, waking at night coughing or choking, or night sweats.• GI: The patient denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids.• GU: The patient denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted diseases.• Musculoskeletal: The patient denies arm, buttock, thigh or calf cramps. No joint or muscle pain. No muscle weakness or tenderness. No joint swelling, neck pain, back pain or major orthopedic injuries.• Skin: The patient denies easy bruising, skin redness, skin rash, hives, sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.• Neurologic: The patient denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss.• Psychiatric: The patient denies depression with thoughts of suicide, voices in ?? head telling ?? to do things and has not been seen for psychiatric counseling or treatment.

Objective Findings

• Vital Signs: Temp 99.2, Pulse 106, Resp 20, BP 136/84, O2 sat 93% at 2LPM

• General: Awake, alert and oriented. No acute distress. Well developed, hydrated and nourished. Appears stated age.• Skin: Skin in warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing.• Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.

• Eyes: Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric.EOM are intact, PERRLA. Fundi appear normal including optic discs and vessels. No signs of nystagmus. Eyelids are normal in appearance without swelling or lesions.• Ears: The external ear and ear canal are non-tender and without swelling. The canal is clear without discharge. The tympanic membrane is normal in appearance with normal landmarks and cone of light. Hearing is intact with good acuity to whispered voice.• Nose: Nasal mucosa is pink and moist. The nasal septum is midline. Nares are patent bilaterally.

• Throat: Oral mucosa is pink and moist with good dentition. Tongue normal in

appearance without lesions and with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is normal in appearance without tonsillar swelling or exudates.• Neck: The neck is supple without adenopathy. Trachea is midline. Thyroid gland is normal without masses. Carotid pulse 2+ bilaterally without bruit. No JVD.• Cardiac: The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal. No murmurs, gallops, or rubs are auscultated. S1 and S2 are heard and are of normal intensity.• Respiratory: Expiratory wheezes heard throughout; Crackles noted in RLL Increased respiratory effort • Abdominal: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation.Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted.• Genital/Rectal: Normal rectal sphincter tone. No external masses or lesions. Stool is normal in appearance. guac negative.• Spine: Neck and back are without deformity, external skin changes, or signs of trauma.Curvature of the cervical, thoracic, and lumbar spine are within normal limits. Bony features of the shoulders and hips are of equal height bilaterally. Posture is upright, gait is smooth, steady, and within normal limits.• No tenderness noted on palpation of the spinous processes. Spinous processes are midline. Cervical, thoracic, and lumbar paraspinal muscles are not tender and are without spasm.• No discomfort is noted with flexion, extension, and side-to-side rotation of the cervical spine, full range of motion is noted. Full range of motion including flexion, extension, and side-to-side rotation of the thoracic and lumbar spine are noted and without discomfort.